Provider Demographics
NPI:1104145531
Name:WHITE, BRODY RAY (DC)
Entity type:Individual
Prefix:DR
First Name:BRODY
Middle Name:RAY
Last Name:WHITE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-1906
Mailing Address - Country:US
Mailing Address - Phone:719-468-2717
Mailing Address - Fax:719-468-2427
Practice Address - Street 1:1120 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1906
Practice Address - Country:US
Practice Address - Phone:719-468-2717
Practice Address - Fax:719-468-2427
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6535111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor